Program Integrity refers to activities designed to prevent, deter, discover, detect, investigate, examine, prosecute, xxx with respect to, defend against, correct, remedy, or otherwise combat health care fraud, waste, or abuse, to include the improper payments in the PMA’s Medicaid program. When done by a HIPAA-covered entity, these are the “health care fraud and abuse detection or compliance” activities described in the fourth paragraph of the HIPAA Privacy Rule’s definition of “Health Care Operations,” and at 45 CFR § 164.506(c)(4). When done by a government actor under a legal mandate, these activities may qualify as “Health Care Oversight” under the HIPAA Privacy Rule.
Program Integrity. As defined by CMS, it is the commitment to combating Medicaid provider fraud, waste, and abuse which diverts dollars that could otherwise be spent to safeguard the health and welfare of Medicaid enrollees. This includes, but is not limited to, the responsibility to review Medicaid provider activities, audit claims, identify and recover overpayments, and provider and public education. Prospective Risk Adjustment: Per 42 CFR §438.5(a), a methodology to account for anticipated variation in risk levels with the contracted HMO that is derived from historical experience of the contracted HMO and applied to rates for the rating period for which the certification is submitted. Protected Health Information (PHI): Health information, including demographic, that relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the payment for the provision of health care to an individual, that identifies the individual or provides a reasonable basis to believe that it can be used to identify an individual. PHI is a subset of IIHI. Provider: A person who has been enrolled by the Department to provide health care services to members and to be reimbursed by BadgerCare Plus and/or Medicaid SSI for those services. Provider Network: A list of physicians, hospitals, urgent care centers, and other health care providers that an HMO has contracted with to provide medical care to its members. These providers are “network providers,” “in-network providers” or “participating providers.” A provider that has not contracted with the plan is called an “out-of-network provider” or “non-participating provider.”
Program Integrity. The process of identifying and referring any suspected Fraud or Abuse activities or program vulnerabilities.
Examples of Program Integrity in a sentence
The State assures CMS that it complies with section 1932(d)(1) of the Act and 42 CFR 438.608 Program Integrity Requirements, in so far as these regulations are applicable.State payments to an MCO or PIHP are based on data submitted by the MCO or PIHP.
Please identify each regulatory requirement for which a waiver is requested, the managed care program(s) to which the waiver will apply, and what the State proposes as an alternative requirement, if any: The CMS Regional Office has reviewed and approved the MCO or PIHP contracts for compliance with the provisions of section 1932(d)(1) of the Act and 42 CFR 438.604 Data that must be Certified; 438.606 Source, Content , Timing of Certification; and 438.608 Program Integrity Requirements.
Guidance: The State should also complete Section 3.10 (Program Integrity).
Guidance: The State should complete Section 11 (Program Integrity) in addition to Section 3.10.
The SIU Manager shall report to the Compliance Officer and meet with the OMPP Program Integrity (OMPP PI) Unit at a minimum of quarterly or more frequently as directed by the OMPP PI Unit.
More Definitions of Program Integrity
Program Integrity means a system of reasonable and consistent oversight of the Medicaid program. Program Integrity effectively encourages compliance; maintains accountability; protects public funds; supports awareness and responsibility; ensures providers, contractors and subcontractors meet participation requirements; ensures services are medically necessary; and ensures payments are for the correct amount and for covered services. The goal of Program Integrity is to reduce and eliminate Fraud, Waste and Abuse (FWA) in the Medicaid program. Program Integrity activities include prevention, algorithms, investigations, audits, reviews, recovery of improper payments, education, and cooperation with Medicaid Fraud Control Unit, and other state and federal agencies. See chapter 182-502A WAC.
Program Integrity. As defined by CMS, it is the commitment to combating Medicaid provider fraud, waste, and abuse which diverts dollars that could otherwise be spent to safeguard the health and welfare of Medicaid enrollees. This includes, but is not limited to, the responsibility to review Medicaid provider activities, audit claims, identify and recover overpayments, and provider and public education. Provider: A person who has been enrolled by the Department to provide health care services to members and to be reimbursed by Medicaid for those services. Provider Network: A list of physicians, hospitals, urgent care centers, and other health care providers that a County has contracted with to provide medical care to its members. These providers are “network providers,” “in-network providers” or “participating providers”. A provider that has not contracted with the plan is called an “out-of-network provider” or “non-participating provider.” Public institution: An institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control as defined by federal regulations, including but not limited to prisons and jails. Recipient: Any individual entitled to benefits under Title XIX and Title XXI of the Social Security Act and under the Medicaid State Plan as defined in Chapter 49, Wis. Stats.
Program Integrity. As defined by CMS, it is the commitment to combating Medicaid provider fraud, waste, and abuse which diverts dollars that could otherwise be spent to safeguard the health and welfare of Medicaid enrollees. This includes, but is not limited to, the responsibility to review Medicaid provider activities, audit claims, identify and recover overpayments, and provider and public education. Provider: A person who has been enrolled by the Department to provide health care services to members and to be reimbursed by Medicaid for those services. Provider Network: A list of physicians, hospitals, urgent care centers, and other health care providers that a County has contracted with to provide medical care to its members. These providers are “network providers,” “in-network providers” or “participating providers”. A provider that has not contracted with the plan is called an “out-of-network provider” or “non-participating provider.”
Program Integrity means the process of identifying and referring any suspected Fraud or Abuse activities or program vulnerabilities concerning the health care services to the Cabinet’s Office of the Inspector General. Prospective Drug Utilization Review (ProDUR) means a monitoring system that screens prescription drug claims to identify problems such as therapeutic duplication, drug-disease contraindications, incorrect dosage or duration of treatment, drug allergy, and clinical misuse or abuse. Protected Health Information (PHI) means individual patient demographic information, Claims data, insurance information, diagnosis information, and any other care or payment for health care that identifies the individual (or there is reasonable reason to believe could identify the individual), as defined by HIPAA. Provider means any person or entity under contract with the Contractor or its contractual agent that provides Covered Services to Members. Psychiatric Residential Treatment Facilities (PRTF) means a non-hospital facility that has a provider agreement with the Department to provide inpatient services to Medicaid-eligible individuals under the age of 21 who require treatment on a continuous basis as a result of a severe mental or psychiatric illness. The facility must be accredited by JCAHO or other accrediting organization with comparable standards recognized by the Commonwealth. PRTFs must also meet the requirements in §441.151 through 441.182 of the CFR. QAPI means quality assessment and performance improvement. Quality Improvement (QI) means the process of assuring that Covered Services provided to Members are appropriate, timely, accessible, available, and Medically Necessary and the level of performance of key processes and outcomes of the healthcare delivery system are improved through the Contractor’s policies and procedures. Quality Management means the integrative process that links knowledge, structure and processes together throughout the Contractor’s organization to assess and improve quality.
Program Integrity means the process of identifying and referring any suspected Fraud or Abuse activities or program vulnerabilities concerning the health care services to the Cabinet’s Office of the Inspector General. Prospective Drug Utilization Review (ProDUR) means a monitoring system that screens prescription drug claims to identify problems such as therapeutic duplication, drug-disease contraindications, incorrect dosage or duration of treatment, drug allergy, and clinical misuse or abuse, as required by 42 CFR 438.3(s) and complies with 1927(g) and 42 CFR part 456, subpart K. Protected Health Information (PHI) means individual patient demographic information, Claims data, insurance information, diagnosis information, and any other care or payment for health care that identifies the individual (or there is reasonable reason to believe could identify the individual), as defined by HIPAA. Provider means any person or entity under contract with the Contractor or its contractual agent that provides Covered Services to Members. Psychiatric Residential Treatment Facilities (PRTF) means a non-hospital facility that has a provider agreement with the Department to provide inpatient services to Medicaid-eligible individuals under the age of 21 who require treatment on a continuous basis as a result of a severe mental or psychiatric illness. The facility must be accredited by JCAHO or other accrediting organization with comparable standards recognized by the Commonwealth. PRTFs must also meet the requirements in §441.151 through 441.184 of the CFR. QAPI means quality assessment and performance improvement program, as required by 42 CFR 438.330. Quality Improvement (QI) means the process of assuring that Covered Services provided to Members are appropriate, timely, accessible, available, and Medically Necessary and the level of performance of key processes and outcomes of the healthcare delivery system are improved through the Contractor’s policies and procedures. Quality Management means the integrative process that links knowledge, structure and processes together throughout the Contractor’s organization to assess and improve quality.
Program Integrity. Gainful Employment; Correction,” Sec. 668.414. (“…each eligible program it offers satisfies the applicable educational prerequisites for professional licensure or certification requirements in that State so that a student who completes the program and seeks employment in that State qualifies to take any licensure or certification exam that is needed for the student to practice or find employment in an occupation that the program prepares students to enter.”) Available at: xxxxx://xxx.xxxxxxxxxxxxxxx.xxx/documents/2018/08/14/2018-17531/program-integrity-gainful-employment.
Program Integrity means a system of reasonable and consistent oversight of the Medicaid program. Program Integrity effectively encourages compliance; maintains accountability; protects public funds; supports awareness and responsibility; ensures providers, contractors and subcontractors meet participation requirements; ensures services are medically necessary; and ensures payments are for the correct amount and for covered services. The goal of Program Integrity is to reduce and eliminate Fraud, Waste, and Abuse (FWA) in the Medicaid program. Program Integrity activities include prevention, algorithms, investigations, audits, reviews, recovery of improper payments, education, and cooperation with Medicaid Fraud Control Unit, and other state and federal agencies. See chapter 182-502A WAC.